Effective Date:  12/7/98


Policy Statement:

The minimum requirements for documents that comprise a client's case record are:

  • Child Care Application - Form 3455, Form 3455S*
  • Approval of Request for Child Care Payments - Form 3455A, 3455AS*
  • Denial of Request for Child Care Payments - Form 4179, 4179S*
  • Notice of Cancellation for Child Care Payments - Form 4178, 4178S*
  • Child Care Certificates - Form 3492, 3492A, or 3492B
  • Request for Additional Information - Form 4480, 4480S*
  • Request for a Child Care Provider Change - Form 3455G, 3455GS*
  • Request for Redetermination Information - Form 3455E, 3455ES*
  • Request for Reimbursement - Form 3455F
  • Two most recent and consecutive pay stubs or other income documentation
  • Responsibility and Service Plan (RSP) or other appropriate local office documentation

*Spanish version of the form.

The documents listed above are not required to be physically maintained in the same case record.

CCR&R Directors and Site Administered Providers must establish adequate internal controls to ensure that files are maintained in a logical fashion and retrieval is possible without excessive delays.

If possible, documents comprising the file should be original, including original signatures, and be complete.

A case record may also contain other information in addition to the minimum requirements. Examples of other information are case notes, documentation of a phone conversation, and written correspondence.